Dilip NathwaniNinewells Hospital & Medical School

Dundee, Scotland DD1 9SY

SCOTTISH ANTIMICROBIAL PRESCRIBING

GROUP (SAPG) 2008

Where are we now and why?

Antimicrobial Prescribing Facts

~ 1/3 of all hospitalised inpatients at any given time receive antibiotics

~ up to 1/3 to ½ are inappropriate ~ up to 30% of all surgical prophylaxis in

inappropriate Antimicrobials account for upwards of 30% of

hospital pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets.

Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences , increased morbidity, mortality,increased cost, increased litigation and reduce quality of life

“The desire to ingest medicines is one of the principal features which distinguish man from the animals”

Osler W.Aecquanimitas,1920

OVERUSE

Why So Many Mistakes

High number and complexity of drugsHigh number and complexity of

syndromes and pathogensPoor training in antibiotic useVariability over time and place in

- pathogen prevalence- antibiotic susceptibilities- antibiotic formularies

Interventions to improve antibiotic prescribing practices for hospital inpatients Cochrane Systematic Review

Interventions to improve antibiotic prescribing practices for hospital inpatients Cochrane Systematic Review

Intervention Outcome Good

evidence

Weak evidence

No evidence

Restriction of third generation cephalosporins

Resistant gram –ve bacteria

Carling

de Man

Calil

Landman

Meyer

Leverstein van Hall

CDAD Carling McNulty

Khan

MRSACarling

Landman

VRE Bradley

Restriction of aminoglycosides

Resistant gram –ve bacteria

De Champs

Gerdingi.gould courtesy

Antibiotic use and resistance in the hospital MRSA: temporal series (Aberdeen, 1996-2000)

Monnet et al. Emerg Infect Dis 2004; 10:1432-41

What is Antimicrobial Stewardship?A marriage of infection control and antimicrobial

managementMandatory infection control complianceSelection of antimicrobials from each class of drugs that

does the least collateral damageCollateral damage issues include

- MRSA- ESBLs- C.difficile- stable derepression- MBLs and other carbapenemases- VRE

Appropriate de-escalation when culture results are availableDellit TH et al Clin Infect Dis 2007; 44: 159-177

How can we reduce consumption, improve

quality of prescribing and reduce resistant transmission?

Maintains ResistanceMaintains ResistanceMaintains ResistanceMaintains Resistance

Spreads ResistanceSpreads ResistanceSpreads ResistanceSpreads Resistance

Causes ResistanceCauses ResistanceCauses ResistanceCauses Resistance

Antibiotic UseAntibiotic Use

Cross InfectionCross Infection

Don’t forget antibiotic use to modulate

resistance and control outbreaks eg. patient

decontamination regimens

Antibiotic UseAntibiotic Use

By Patient-staff-patient

Patient-patient

?Patient-environment / equipment – patient

By Patient-staff-patient

Patient-patient

?Patient-environment / equipment – patient

The Vicious Spiral

Must get right at all cost Must get right at all cost

Inadequate rapid testInadequate rapid test

Lack of faith in testsLack of faith in tests

Defensive medicineDefensive medicine

Patient expectationsPatient expectations

Poly-pharmacyPoly-pharmacy

Increased prescribingIncreased prescribing & & empiric Rxempiric Rx

costcostResistanceResistance

C.difficleC.difficle

use of new use of new drugsdrugs

Use of broad Use of broad spectrum spectrum

drugsdrugs

Managing risk of empiric therapy

“Many clinicians regard the right to prescribe antibiotics freely (unrestricted) as a basic human right”

However

“The desire of the clinicians to achieve the most optimal outcome for the patient needs to be balanced against the risk to the patient, ecology and other patients of broad spectrum antibiotic use, particularly C.difficle in the most vulnerable group

“The organisation needs to risk manage this conflict and help with solutions “

APP&P KEY DOMAINS FOR RECOMMENDATIONS 2006

Recommendations in the following key areas:Key Area

1. Establish standard structures and lines of responsibility &accountability in NHS Boards across Scotland.

2. Define structures and responsibility for multi-disciplinaryand generic undergraduate and post-graduate trainingrelated to antimicrobial prescribing.

3. Define the minimum dataset requirements and standardprocedures for collecting information related toantimicrobial resistance patterns.

4 Define the minimum dataset requirements and standardprocedures for collecting information related toantimicrobial consumption and quality of prescribing at anorganisational level and/or ward specific level.

5. Define the key areas for acute hospital policy andrecommendations for audit.

6. Develop and define performance indicators that could beused to assess or gauge performance related toantimicrobial prescribing in hospitals

SMC SLWG Document communicated by CMO to all NHS Boards 2006

Medical DirectorMedical Director Chief ExecutiveChief Executive Infection Control Infection Control ManagerManager

Drugs & Drugs & Therapeutics Therapeutics CommitteeCommittee

Antimicrobial Antimicrobial Management Team (AMT)Management Team (AMT)

Speciality-based Pharmacy leads for Speciality-based Pharmacy leads for APP&P with responsibility for APP&P with responsibility for antimicrobial prescribingantimicrobial prescribing

Ward Based Clinical Ward Based Clinical PharmacistsPharmacists

Risk Management Risk Management CommitteeCommittee

Clinical Governance Clinical Governance CommitteeCommittee

Infection Control Infection Control CommitteeCommittee

Microbiologist / Microbiologist / Infectious Diseases Infectious Diseases PhysicianPhysician

PRESCRIBERPRESCRIBER

Prescribing support / feedback

Dissemination & feedback

http://www.scotland.gov.uk

KEY ROLE OF AMT

Antimicrobial management team

Multi-disciplinary team ResourcedSupported Multi-faceted

interventions (consistently more effective then single interventions)

Active team at the coalface

Core InterventionsFormulary +

restrictions (expert approval)

Audit and feedback (information) of antimicrobial use and resistance patterns and unintended consequences

THE SCOTTISH MANAGEMENT OF ANTIMICROBIAL

RESISTANCE ACTION PLAN[ScotMARAP 2007]

ScotMARAP Output

3 year programme of work launched on the 17th of March 2008

Total funding of £1.2 million and allocation split between key stakeholders

SMC asked to convene, host and service national clinical forum – SAPG

SCOTTISH ANTIMICROBIAL PRESCRIBING GROUP (SAPG)

The primary role of the SMC is to convene and service a group to fulfil the aspirations for “a national clinical forum” as expressed in the APP&P. This group (SAPG) would include national stakeholder organisations and would collate the disseminate scientifically rigorous information on antimicrobial resistance trends and antimicrobial use on an ongoing basis to the NHS (primary and secondary care).

Scottish Medicines Consortium Scottish Antimicrobial rescribing Group

Health ProtectionScotland

NHS Education forScotland

NHS Boards Area Drug and Therapeutics Committees

NHS Quality Improvement Scotland

NHS Boards Antimicrobial Management Teams

Clinical GovernanceRisk ManagementInfection Control Team /

ManagerPrescribers

Reference DiagnosticServices

NHS Boards Antimicrobial Management Team Sub- Group of Scottish

Antimicrobial Prescribing Group

Scottish Patient Safety Alliance

Information ServicesDivision

Local DiagnosticServices

Scottish Medicines Consortium Scottish Antimicrobial rescribing Group

Health ProtectionScotland

NHS Education forScotland

NHS Boards Area Drug and Therapeutics Committees

NHS Quality Improvement Scotland

NHS Boards Antimicrobial Management Teams

Clinical GovernanceRisk ManagementInfection Control Team /

ManagerPrescribers

Reference DiagnosticServices

NHS Boards Antimicrobial Management Team Sub- Group of Scottish

Antimicrobial Prescribing Group

Scottish Patient Safety Alliance

Information ServicesDivision

Local DiagnosticServices

THE STAKEHOLDERS

4 WORKSTREAMS

1. INFORMATION MANAGEMENT (HPS AND ISD)

2. EDUCATION (NES)3.ORGANISATION AND ACCOUNTABILITY

(NQIS)4.INFECTION MANAGEMENT

(SPA,NQIS,NES,HPS-ISD,Professional Organisations)All the work-streams work in parallel but with vertical

integration Workstream work underpinned by an AMT Clinical

Network

1. INFORMATION MANAGEMENT: SURVEILLANCE AND CONSUMPTION DATA

Overview of Information from NHS Boards Reporting antimicrobial use in DDDs

• 3 NHS Boards – routine reporting in primary & secondary care

• 2 NHS Boards – routine reporting in primary care

• 3 NHS Boards – ad hoc reporting

• 6 NHS Boards – no reporting

2: ORGANISATION & ACCOUTABILITY Overview of Information from NHS Boards Antimicrobial Management

Teams (AMTs)

• 7 out of 14 NHS Boards have established AMTs

4 - primary & secondary care

3 - secondary care only

• Other NHS Boards either have AMT equivalents or seek advice / support from other NHS Boards

• Where AMTs exist there are links with ADTCs (direct or indirect reporting)

• AMTs MUST BE IN PLACE AND ICTs SHOULD SUPPORT THIS

• OVERALL MANAGEMENT BY ICM’s but CEO/Medical Director accountability

CEL 30(2008)8TH July

As an immediate intervention to reduce the risk form C.difficle,we accept SAPG’s recommendation that all boards should immediately establish an AMT which covers primary and secondary care prescribing.

“AMT’s work closely strategically and operationally with ICT’s and ICM”- SAPG

CEL 30(2008)8TH July

Recognition of the key role of the antimicrobial pharmacist: central additional funding for £40,000 for each mainland board and £20k for Island boards for 3 years (2011).

SAPG (not in CEL) keen on developing clinical networks for AMT’s to provide support for smaller boards, share good practice and do joint planning. Launch of AMT clinical network in STIRLING 18TH November 2008.

Education

DOTS onl line- all foundation doctors mandatory training in prescribing

PAUSE website for undergraduates- Scottish Deans Educational Group

Pharmacy and non-medical prescribers programme for prescribing

Module on antibiotic resistance and C.difficile being developed

Nurses programme on recognition of infection and use of microbiology

Dental antibiotic prescribing

4: INFECTION MANAGMENT PHILOSOPHY

HIGH BURDEN, HIGH IMPACT CONDITIONS EVIDENCE OF BENEFIT FOR INTERVENTION ALSO TARGET SYSTEMS CHANGE TO BRING

ABOUT DESIRED BENEFIT INTEGRATE, DEVELOP AND IMPLEMENT

EXISITING AND NEW PROJECTS OVER 3 YEAR TIME FRAME: WORK CLOSELY WITH WORK PROGRAMMES OF KEY STAKEHOLDERS (e.g HPS, SPA)

IMMEDIATE OPPORTUNITIES AROUND SNAP-CAP, C.difficle and Surgical Prophylaxis

Others

The First Six Months of SAPG

Guidance on CDAD- restrictive policy, CDAD management protocol, measures of improvement & set up extra-net

Surgical prophylaxisSNAP-CAPAMT network –November 18th launchAppointment of key personnel National generic prescribing templateAntimicrobial prescribing and resistance

education programme.

Outbreak

June 2000One university

hospital, USIncrease C.difficle

from 2.7 to 7.2 infections per 100 hospital discharges

Increase in the frequency of severe outcomes

“Tiered” as opposed to a “bundle” approach. Implemented over time. Education ¶ Increase in case finding and

rapid initiation of appropriate therapy ¶

Expanded infection control measures

Infection control auditsTargeted antimicrobial

restriction ¶Measuring and feedback of

antibiotic use and local surveillance data

Muto et al CID 2007; 45: 1266-73.

SPCC RWHT C.difficile Toxin

Guidance for Proven or Suspected C. difficile associated diarrhoea

(CDAD)Your patient is in a healthcare facility or has been admitted with new onset of DIARRHOEA

Constipation with overflow diarrhoea (make sure PR done), laxatives and other common causes of diarrhoea have been excluded

Does patient have risk factors for CDAD?History of use (< 3m) or current use of an antibioticProlonged recent hospital stayUse of PPIIncreasing age especially >65ySurgical procedure (in particular bowel procedures)

Send stool for C. difficiletoxin

Inform InfectionControl Team

Isolate patientin single room

Designated toilet or commode

Stop PPIStop anti-microbial

treatment if possibleStop laxative

Hand hygienewith soap and

waterWear gloves

and disposable apron

Toxin -ve Toxin +ve

Continue with guidance

Discontinue C. difficileguidance or if indexof suspicion high seek ID referral

Patient has non-severe CDAD

Treat with oral metronidazole 400mg t.d.s. for 10-14 days Rehydrate patient

Daily assessment of patient with mild to moderate disease:

Observe bowel movement, symptoms (WBC and hypotension) and fluid balance.

If condition doesn’t improve after 3-5 days of treatment with metronidazole, patient should be switched to treatment with vancomycin (125mg q.d.s. for a further 10-14 days)

Treat with oral vancomycin 125mg q.d.s. for 14 days

Rehydrate patient and consider referral to hospital or healthcare facility if patient at home

Daily assessment of patient with severe disease:

Observe bowel movement, symptoms (WBCand hypotension) and fluid balance.

Surgery – Consult and AXR and CT scanning; consider PMC, toxic megacolon, ileus orperforation

If ileus is detected add 500mg metronidazole i.v. t.d.s. until ileus is resolved

Patient has severe CDAD

Contact Details

Infection control team via switchboard

Public health via NWH switch board if care home

“On call” duty microbiologist: 4039 Ninewells or via switchboard 5315 Perth Royal

“On call” ID: 5075

Refer to Infectious Disease

Yes

UNDERTAKE SEVERITY ASSESSMENTSuspicion of Pseudomembranous colitis (PMC) or toxic

megacolon or ileus OR two or more of the following severitymarkersColonic dilatation in CT scan >6cm(if available)WCC >15 cells/mm3

Creatinine >1.5 x baselineAlbumin <25 g/l

For recurrent (3 or moreepisodes) CDAD seekSpecialist ID/Micro advice

Tayside HAI NetworkSeptember 2008

Review September 2009

YesNo

REDUCE TRANSMI SSION

Day 3 Antibiotic Review Bundle : Clinical Diagnosis, Laboratory Results, Duration, Route

Pulcini et al, JAC, 2008

0

5

10

15

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25

30

35

40

Jan-

05

Apr

Jul

Oct

Jan-

06

Apr

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Jan-

07

Apr

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Oct

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08

No.

of C. Diff

Cas

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c-chart for Cases of c. difficile Acquired in Ninewells Hospital: Jan 2005 – Mar 2008

Upper Control Limit

Lower Control Limit

Upper Warning Limit

Lower Warning Limit

CONCLUSIONSSAPG is a national clinical forum with broad multi-

disciplinary ownership. A structure for clinical and fiscal governance is established. SMC is the host organisation.

SAPG is now in operation with 4 key proposed work-streams. These would be key deliverables over specific time frames.

Other areas to be developed over time, especially around primary care and community/LTCF prescribing

AMT clinical network will provide national cohesion and need to work in close collaboration with ICTs and should have a unified vision

We need hospital leadership and all healthcare professionals to engage with it and own it

Your thought of the day : To restrict or not to..?

“Whether ‘tis nobler in the mind to suffer the slings and arrows of outrageous… [prescribing].. or take arms against a sea of.. [resistance and diarrhoea].. and by opposing [antibiotics] end it..”

Adapted from Shakespeare WDilip.nathwani@nhs.net